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Lebeer M, Kaes J, Lambrech M, Vanstapel A, Beeckmans H, Ambrocio GP, Vanaudenaerde BM, Verleden SE, Verbeken EK, Neyrinck AP, Ceulemans LJ, Van Raemdonck DE, Verleden GM, Vos R, Godinas L, Yserbyt J, Dupont LJ, Van Herck A, Sacreas A, Heigl T, Ordies S, Schaevers V, De Leyn P, Coosemans W, Nafteux P, Decaluwé H, Van Veer H, Depypere L, Frick AE, Weynand B, Emonds M, Lievens Y. Total lymphoid irradiation in progressive bronchiolitis obliterans syndrome after lung transplantation: a single‐center experience and review of literature. Transpl Int 2019; 33:216-228. [DOI: 10.1111/tri.13544] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/03/2019] [Accepted: 10/18/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Marnix Lebeer
- Department of Respiratory Diseases University Hospitals Leuven Leuven Belgium
| | - Janne Kaes
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
| | - Maarten Lambrech
- Department of Radiation Oncology University Hospitals Leuven Leuven Belgium
| | - Arno Vanstapel
- Department of Respiratory Diseases University Hospitals Leuven Leuven Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
| | - Hanne Beeckmans
- Department of Respiratory Diseases University Hospitals Leuven Leuven Belgium
| | - Gene P.L. Ambrocio
- Department of Respiratory Diseases University Hospitals Leuven Leuven Belgium
| | - Bart M. Vanaudenaerde
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
| | - Stijn E. Verleden
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
| | | | - Arne P. Neyrinck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
- Department of Anesthesiology University Hospitals Leuven Leuven Belgium
| | - Laurens J. Ceulemans
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
- Department of Thoracic Surgery University Hospitals Leuven Leuven Belgium
| | - Dirk E. Van Raemdonck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
- Department of Thoracic Surgery University Hospitals Leuven Leuven Belgium
| | - Geert M. Verleden
- Department of Respiratory Diseases University Hospitals Leuven Leuven Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
| | - Robin Vos
- Department of Respiratory Diseases University Hospitals Leuven Leuven Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE) Department of Chronic Diseases, Metabolism & Ageing (CHROMETA) KU Leuven Leuven Belgium
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Other Forms of Immunosuppression. KIDNEY TRANSPLANTATION - PRINCIPLES AND PRACTICE 2019. [PMCID: PMC7152196 DOI: 10.1016/b978-0-323-53186-3.00020-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
OBJECTIVES Although there have been tremendous advancements in the care of severe pediatric cardiovascular disease, heart transplantation remains the standard therapy for end-stage heart disease in children. As such, these patients comprise an important and often complex subset of patients in the ICU. The purpose of this article is to review the causes and management of allograft dysfunction and the medications used in the transplant population. DATA SOURCES MEDLINE, PubMed, and Cochrane Database of systemic reviews. CONCLUSIONS Pediatric heart transplant recipients represent a complex group of patients that frequently require critical care. Their immunosuppressive medications, while being vital to maintenance of allograft function, are associated with significant short- and long-term complications. Graft dysfunction can occur from a variety of etiologies at different times following transplantation and remains a major limitation to long-term posttransplant survival.
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Abicht J, Mayr T, Reichart B, Buchholz S, Werner F, Lutzmann I, Schmoeckel M, Bauer A, Thormann M, Langenmayer M, Herbach N, Pohla H, Herzog R, McGregor CGA, Ayares D, Wolf E, Klymiuk N, Baehr A, Kind A, Hagl C, Ganswindt U, Belka C, Guethoff S, Brenner P. Pre‐clinical heterotopic intrathoracic heart xenotransplantation: a possibly useful clinical technique. Xenotransplantation 2015; 22:427-42. [DOI: 10.1111/xen.12213] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/19/2015] [Indexed: 01/24/2023]
Affiliation(s)
- Jan‐Michael Abicht
- Department of Anaesthesiology Ludwig‐Maximilian University Munich Germany
- Transregio Collaborative Research Center 127 Walter Brendel Centre of Experimental Medicine Ludwig Maximilian University Munich Germany
| | - Tanja Mayr
- Department of Anaesthesiology Ludwig‐Maximilian University Munich Germany
- Transregio Collaborative Research Center 127 Walter Brendel Centre of Experimental Medicine Ludwig Maximilian University Munich Germany
| | - Bruno Reichart
- Transregio Collaborative Research Center 127 Walter Brendel Centre of Experimental Medicine Ludwig Maximilian University Munich Germany
| | - Stefan Buchholz
- Department of Cardiovascular Surgery Ludwig Maximilian University Munich Germany
| | - Fabian Werner
- Department of Cardiovascular Surgery Ludwig Maximilian University Munich Germany
| | - Isabelle Lutzmann
- Department of Cardiovascular Surgery Ludwig Maximilian University Munich Germany
| | - Michael Schmoeckel
- Department of Cardiovascular Surgery Ludwig Maximilian University Munich Germany
- Department of Cardiac Surgery Asklepios Klinik St Georg Hamburg Germany
| | - Andreas Bauer
- Department of Anaesthesiology Ludwig‐Maximilian University Munich Germany
| | - Michael Thormann
- Department of Cardiovascular Surgery Ludwig Maximilian University Munich Germany
| | - Martin Langenmayer
- Institute of Veterinary Pathology Ludwig Maximilian University Munich Germany
| | - Nadja Herbach
- Institute of Veterinary Pathology Ludwig Maximilian University Munich Germany
| | - Heike Pohla
- Tumor Immunology Laboratory LIFE Center Ludwig Maximilian University Munich Germany
| | - Rudolf Herzog
- Transregio Collaborative Research Center 127 Walter Brendel Centre of Experimental Medicine Ludwig Maximilian University Munich Germany
| | | | | | - Eckhard Wolf
- Department of Molecular Animal Breeding and Biotechnology Ludwig Maximilian University Munich Germany
| | - Nikolai Klymiuk
- Department of Molecular Animal Breeding and Biotechnology Ludwig Maximilian University Munich Germany
| | - Andrea Baehr
- Department of Molecular Animal Breeding and Biotechnology Ludwig Maximilian University Munich Germany
| | - Alexander Kind
- Chair of Livestock Biotechnology School of Life Sciences Weihenstephan Technical University of Munich Germany
| | - Christian Hagl
- Department of Cardiovascular Surgery Ludwig Maximilian University Munich Germany
| | - Ute Ganswindt
- Department of Radiation Oncology Ludwig Maximilian University Munich Germany
| | - Claus Belka
- Department of Radiation Oncology Ludwig Maximilian University Munich Germany
| | - Sonja Guethoff
- Transregio Collaborative Research Center 127 Walter Brendel Centre of Experimental Medicine Ludwig Maximilian University Munich Germany
- Department of Cardiovascular Surgery Ludwig Maximilian University Munich Germany
| | - Paolo Brenner
- Transregio Collaborative Research Center 127 Walter Brendel Centre of Experimental Medicine Ludwig Maximilian University Munich Germany
- Department of Cardiovascular Surgery Ludwig Maximilian University Munich Germany
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Ramanathan R, Sharma A, Kaspar M, Behnke M, Song S, Stravitz RT, Cotterell A, Posner M, Fisher RA. Local allograft irradiation as an adjunct for treating severe resistant rejection after liver transplantation in adults. Liver Transpl 2015; 21:47-56. [PMID: 25287272 DOI: 10.1002/lt.24016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 09/10/2014] [Accepted: 09/11/2014] [Indexed: 02/07/2023]
Abstract
Acute rejection after liver transplantation occurs in one-third of all recipients and can be managed with conventional rejection therapy in the majority of cases. In rare instances, patients with severe acute rejection may be refractory to or have contraindications for conventional therapies. This case series evaluates the role of local allograft irradiation (LAI) as an adjunct for patients with rejection that is refractory to or contraindicated for conventional therapies. Additionally, the literature on the use of radiation therapy for reversing rejection in solid organ transplantation is reviewed. Five patients underwent 9 LAI treatments: 2 had refractory rejection, and 1 each had a malignancy, a concurrent life-threatening infection, and serum sickness with antibody therapy. Conventional rejection therapies included steroids, calcineurin inhibitors, and antithymocyte globulin. LAI consisted of 3 cycles of 1.5 Gy directed toward the liver allograft. Two of the 5 patients remained alive with excellent graft function. Six of the 9 treatments were successful in rescuing the liver allograft (reversing the rejection episode). Treatment success was associated with lower pretreatment serum bilirubin levels and higher pretreatment alanine aminotransferase levels. Compared with patients with immunosuppression-responsive severe acute rejection, those requiring LAI trended toward a later onset of first rejection. In conclusion, local irradiation of liver allografts can be a useful adjunct in patients for whom conventional options have been exhausted or cannot be used. The ability of LAI to reverse allograft dysfunction and promote patient survival appears to be greatest before the onset of severe cholestatic injury.
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Affiliation(s)
- Rajesh Ramanathan
- Hume-Lee Transplant Center, Virginia Commonwealth University Medical Center, Richmond, VA
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Hildebrandt GC, Fazekas T, Lawitschka A, Bertz H, Greinix H, Halter J, Pavletic SZ, Holler E, Wolff D. Diagnosis and treatment of pulmonary chronic GVHD: report from the consensus conference on clinical practice in chronic GVHD. Bone Marrow Transplant 2011; 46:1283-95. [PMID: 21441964 PMCID: PMC7094778 DOI: 10.1038/bmt.2011.35] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 11/12/2010] [Accepted: 11/16/2010] [Indexed: 01/03/2023]
Abstract
This consensus statement established under the auspices of the German working group on BM and blood stem cell transplantation (DAG-KBT), the German Society of Hematology and Oncology (DGHO), the Austrian Stem Cell Transplant Working Group, the Swiss Blood Stem Cell Transplantation Group (SBST) and the German-Austrian Pediatric Working Group on SCT (Päd-Ag-KBT) summarizes current evidence for diagnosis, immunosuppressive and supportive therapy to provide practical guidelines for the care and treatment of patients with pulmonary manifestations of chronic GVHD (cGVHD). Pulmonary cGVHD can present with obstructive and/or restrictive changes. Disease severity ranges from subclinical pulmonary function test (PFT) impairment to respiratory insufficiency with bronchiolitis obliterans being the only pulmonary complication currently considered diagnostic of cGVHD. Early diagnosis may improve clinical outcome, and regular post-transplant follow-up PFTs are recommended. Diagnostic work-up includes high-resolution computed tomography, bronchoalveolar lavage and histology. Topical treatment is based on inhalative steroids plus beta-agonists. Early addition of azithromycin is suggested. Systemic first-line treatment consists of corticosteroids plus, if any, continuation of other immunosuppressive therapy. Second-line therapy and beyond includes extracorporeal photopheresis, mammalian target of rapamycin inhibitors, mycophenolate, etanercept, imatinib and TLI, but efficacy is limited. Clinical trials are urgently needed to improve understanding and treatment of this deleterious complication.
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Affiliation(s)
- G C Hildebrandt
- Department of Hematology and Oncology, University of Regensburg Medical Center, Regensburg, Germany.
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Tailored total lymphoid irradiation in heart transplant patients: 10-years experience of one center. Radiat Oncol 2010; 5:3. [PMID: 20078889 PMCID: PMC2822786 DOI: 10.1186/1748-717x-5-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Accepted: 01/16/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To assess safety and efficacy of tailored total lymphoid irradiation (tTLI) in cardiac transplant patients. METHODS A total of seven patients, of which five had recalcitrant cellular cardiac allograft rejection (RCCAR), confirmed by endomyocardial biopsies, and two had side effects of immunosuppressive drug therapy, were all treated with tTLI. tTLI was defined by the adjustment of both the fraction interval and the final irradiation dosage both being dependent on the patients general condition, irradiation-dependent response, and the white blood and platelet counts. A mean dose of 6.4 Gy (range, 1.6 - 8.8 Gy) was given. Median follow-up was 7 years (range, 1.8 - 12.2 years). RESULTS tTLI was well tolerated. Two patients experienced a severe infection during tTLI (pneumocystis jirovecii pneumonia, urosepsis and generalized herpes zoster) and one patient developed a lymphoproliferative disorder after tTLI. The rate of rejection episodes before tTLI was 0.43 episodes/patient/month and decreased to 0.02 episodes/patient/month after tTLI (P < .001). At the end of the observation time, all patients except one were alive. CONCLUSIONS tTLI is a useful treatment strategy for the management of RCCAR and in patients with significant side effects of immunosuppressive drug therapy. In this series tTLI demonstrated significantly decreased rejection rates without causing relevant treatment-related toxicity.
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Ameduri RK, Canter CE. Current practice in immunosuppression in pediatric cardiac transplantation. PROGRESS IN PEDIATRIC CARDIOLOGY 2009. [DOI: 10.1016/j.ppedcard.2008.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abd-Allah S, Checchia PA. Heart Transplantation. CARDIOVASCULAR PEDIATRIC CRITICAL ILLNESS AND INJURY 2009:1-22. [DOI: 10.1007/978-1-84800-923-3_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Lim TS, O’Driscoll G, Freund J, Peterson V, Hayes H, Heywood J. Short-course Total Lymphoid Irradiation for Refractory Cardiac Transplantation Rejection. J Heart Lung Transplant 2007; 26:1249-54. [DOI: 10.1016/j.healun.2007.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Revised: 08/29/2007] [Accepted: 09/12/2007] [Indexed: 10/22/2022] Open
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Nagasaki K, Obara H, Xiong A, Kambham N, Strober S, Esquivel CO, Millan MT. Liver allografts are toleragenic in rats conditioned with posttransplant total lymphoid irradiation. Transplantation 2007; 84:619-28. [PMID: 17876275 DOI: 10.1097/01.tp.0000278104.15002.64] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Posttransplant total lymphoid irradiation (TLI) treatment has been applied to tolerance induction protocols in heart and kidney transplantation models. METHODS We examined the efficacy and mechanism of posttransplant TLI treatment in the induction and maintenance of tolerance in a rat orthotopic liver transplantation model. RESULTS Posttransplant TLI prolonged ACI (RT1(a)) liver allograft survival in Lewis (RT1(b)) hosts, with 50% long-term engraftment without immunosuppression and without evidence of chronic rejection. Injection of donor-type liver mononuclear cells (LMCs) facilitated the prolongation of graft survival, with more than 70% of grafts in LMC recipients surviving more than 100 days without chronic rejection. Recipients with long-term liver allograft survival accepted ACI but not PVG skin grafts. In TLI-conditioned recipients with accepted grafts, apoptosis occurred predominantly in graft-infiltrating leukocytes. In contrast, there were few apoptotic leukocytes in rejecting grafts. Recipients with long-term graft acceptance (>100 days of survival) demonstrated evidence of immune deviation; mixed lymphocyte reaction to ACI stimulator cells was vigorous, but secretion of interferon-gamma and interleukin-2 was reduced. In tolerant recipients, the number of Foxp3(+) CD25(+) CD4(+) regulatory T cells was increased in the liver allograft as well as in the peripheral blood. CONCLUSION We conclude that posttransplant TLI induces tolerance to liver allografts via a mechanism involving apoptotic cell-deletion and immunoregulation.
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Affiliation(s)
- Kazuhito Nagasaki
- Department of Surgery, Division of Transplantation, Stanford University School of Medicine, Stanford, CA, USA
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Wilmot I, Kanter KR, Vincent RN, Berg AM, Mahle WT. OKT3 Treatment in Refractory Pediatric Heart Transplant Rejection. J Heart Lung Transplant 2005; 24:1793-7. [PMID: 16297784 DOI: 10.1016/j.healun.2005.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2004] [Revised: 02/01/2005] [Accepted: 02/07/2005] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The anti-lymphocyte monoclonal antibody OKT3 has been shown to be effective in the management of steroid-resistant and/or fulminant heart transplant rejection in adults. In addition, some studies suggest that OKT3 may have a role in the management of transplant coronary artery disease (TxCAD). To date, there are limited data regarding the use of OKT3 treatment of refractory rejection or graft failure in children. Our study examines OKT3 treatment in steroid-resistant rejection, rejection with hemodynamic compromise, and TxCAD in children. METHODS Thirty-eight patients received 53 courses of OKT3 for treatment of rejection and/or graft dysfunction. Primary indications for OKT3 were steroid-resistant rejection (n = 27), rejection with hemodynamic compromise (n = 22), and TxCAD (n = 4). Resolution of rejection was considered absence of biopsy-proven rejection (< grade 2) or resolved TxCAD. RESULTS OKT3 use in steroid-resistant rejection was associated with a lower incidence of rejection in the 3 months after OKT3 than 3 months before OKT3, median rejection episodes of 2.5 vs 0, p < 0.0001. In rejection with hemodynamic compromise, 20 subjects (91%) demonstrated improved hemodynamics after OKT3 and survived to hospital discharge. The use of OKT3 treatment for TxCAD failed to demonstrate resolution or improvement in angiographic TxCAD in any subject. Only 5 OKT3 treatment courses were stopped secondary to severe adverse side effects. CONCLUSIONS OKT3 treatment in refractory pediatric heart transplant rejection is efficacious in acute rejection. OKT3 management in pediatric TxCAD is less clear, with no proven benefit identified in this study. OKT3 use in pediatric refractory heart rejection has significant side effects, but is tolerable and safe with close monitoring.
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Affiliation(s)
- Ivan Wilmot
- Egleston Children's Hospital, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Abstract
PURPOSE OF REVIEW Advances in immunosuppression have contributed to the significant improvements in outcome for pediatric heart transplant recipients in the past two decades. The large increase in the number of available immunosuppressive agents in the past few years mandates that those caring for this complex group of patients remain up to date in this rapidly advancing field. RECENT FINDINGS In this review, we evaluate recent studies of immunosuppressive efficacy, end-organ toxicities, and side effects of nonspecific immunosuppression with currently used regimens. In addition, we examine new findings that attempt to define the genetic contribution to rejection profiles, immunosuppressive efficacy, and drug disposition after heart transplantation in children. SUMMARY The continuous evaluation of new immunosuppressive regimens will help to elucidate the optimal treatment regimens for pediatric heart transplant recipients. Unfortunately, the small number of transplantations means that it is unlikely that pivotal randomized, controlled trials will ever be performed in this population. Extrapolation from adult controlled trials and experience from other pediatric solid organ transplant recipient populations will continue to provide important contributions to our knowledge base. Understanding the genetic contribution to graft and patient outcomes may help us tailor immunosuppressive therapy for the individual patient.
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Affiliation(s)
- Linda M Russo
- Division of Pediatric Cardiology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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